Chronic Wounds — Dennis' Story

Dennis was angry. Again.

Dr. Halsted, his family practice doctor, still hadn't beckoned him into his 3:15 appointment...leaving Dennis feeling as if he were about to ooze his life away in this turquoise and beige waiting room.

Plus, Dennis didn't think Dr. Halsted would approve of everything he had to report: yes, he'd bought one-percent milk, which the doctor had recommended for managing his high cholesterol, but, guess what -- he also bought cigarettes, ("Lady Janes," his favorites) which Dr. Halsted said he shouldn't be smoking at all.

Dennis was funny that way: he spent his entire life pursuing some things that he shouldn't, (smoking) and then doggedly tried to improve on the over-all bad situation (one-percent milk).

What wasn't funny, was his constant companion of pain from chronic wounds.

His wound, he called it "Beth" (after an ex-girlfriend who broke his heart), was heavily weepy on his left calf. "Beth," a venous stasis ulcer, 5.5 centimeters by 7.0 centimeters by 0.3 centimeters, ultimately erupted as a result of Dennis' chronic venous insufficiency.

"Beth" festered into being a few months ago at the Fresno State reunion picnic. That's where Dennis was so intent on nabbing the last ham-and-lettuce-and-mayonnaise roll that glistened in the midday sun on the big, clear plastic serving platter — that he hadn't really paid attention to just how much he was actually scratching the huge, pink mosquito bite on his leg.

He scratched so hard, the bloody, infected, torn-open bite churned into "Beth," his won't-go-away venous ulcer: loaded with bacteria, oozing yellow gunk, tissue-inflamed, throbbing...all exacerbated by insufficient blood not chugging the way it's supposed to through Dennis' weak veins.

"Oh, ho! There he is!" Dr. Halsted, Dennis' avuncular family practice doctor finally emerged into the waiting room...with all of the blustery clatter that a 73-year-old, long-established primary care physician has a right to.

Since his practice had slowed a bit in the past few years, Dr. Halsted, pleasingly white-haired and double-chinned, made a habit of greeting his patients personally — often sitting right down with them in the waiting room, the way a friendly waiter named "Chad" at a vegan restaurant might join his diners at their table...just before recommending the tofu Mee Krob.

"Ooh, that looks nasty." Dr. Halsted squinted through his bifocals at the wound on Dennis' left calf. "The good news is, though, I'm not so sure it's a venous stasis ulcer, which you'd Googled. It could just be a bad skin tear or a blister gone wrong."

Dr. Halsted reassuringly patted Dennis' leg. "Come into my office. We'll fix you up with some nice Silvadene cream and Betadine ointment. I also recommend that you sit in a healing whirlpool at least twice a day. Yes, sir! We'll get that wound gone in a jiffy!"

Three months later…

Was Dennis angry now or just frustrated? Or...was the blurred line between the two emotions just as soggy as the ever-widening circumference of his worsening wound?

"I don't know, doc," Dennis said, helplessly waving his meaty hands. "It's bigger, it's drippier...and my leg's really blown up. It's swollen like a big old balloon. You said this wound would get better, but it's worse!"

He didn't mention that while "Beth," the wound, agitated on his leg, memories of Beth the ex-girlfriend, burrowed more pain into his heart.

He'd called her voicemail several times over this past six months, leaving no message save for the background sound of the screaming fire engines that often roared down his street.

"Well," Dr. Halsted clumsily clunked-off his round, wire-framed glasses, then rubbed his deeply-bagged eyes. "Look, Dennis, I...I don't know. Maybe I'm not as up-to-date on this stuff as I thought. Besides," Dr. Halsted's watery, blue eyes flicked to a framed photo of his smiling, brunette wife. She stood in front of their family Grand piano, her hand resting proudly by the keys. Dennis once thought he might want to play the piano...but he could never be bothered to practice.

"Besides," Dr. Halsted wearily continued, "Gloria left me for the Fed Ex man. Can you believe that? The Fed Ex man!?!"

Dennis didn't say anything. Wasn't this doctor's appointment supposed to be about him?

"Okay," Dr. Halsted picked up the vibe. "Why don't I refer you to a good vascular surgeon? Dr. Rinoie." Dr. Halsted scribbled some information on a pad. "He's a young guy, really with-it. I know him from my rounds at the hospital. I'll tell him to expect your call."

A week later…

Dr. Rinoie's office was certainly clean, Dennis had to give him that...and the guy looked as if he were in good shape: he had the lean, vein-rippled arms of a man who lifted weights and who didn't eat hamburgers. Beth used to say she found men like that attractive. Heck, this guy probably ate salads with those sprout things on them, Dennis mused. Would Beth find that attractive, too?

"I want to help you, Dennis," Dr. Rinoie, the vascular surgeon, said in a no-nonsense manner. "Operating on your perforating veins is, at least, one step in the right direction. Do you know much about why you got this wound in the first place?"

"Well, I scratched a big mosquito bite and, then, I don't just never healed."

"Okay. Do you know anything about venous insufficiency?"

"Just what I read about on the internet, Doc," Dennis chuckled, trying to establish a we're-just-a-couple-of-guys-talking-about-disease familiarity. "But it all gets really complicated, so then I usually fall asleep with the television on."

Dr. Rinoie chuckled, too, yet maintained a laser-like intensity to his gaze. "I'm assuming that you're often kept awake from your pain? That you have acute discomfort during rest, movement, attempted sleep and every other state of being — making your life, at times, practically unbearable?"

"Um...yeah." Okay. This guy was good.

"Well, Dennis, I believe you have chronic venous insufficiency," Dr. Rinoie continued. "Raging venous pressure, due to reflux in your veins, makes healing your chronic wound an ongoing battle. We'll order an ultra sound to get an exact look at your circulation, which I think is poor, and the specific details of your venous reflux, but... it's fairly clear to me that you have all the symptoms of chronic venous insufficiency: your wound is mired in venous stasis because your superficial veins are over-dilated and exhausted. Your vein valves are weak — they can't handle pumping enough oxygen-poor blood back to your heart."

"This wound stinks, too, Doc. I try using cologne, but, um..." Dennis let the sentence drift off.

"Yes, that's a symptom, as well: foul odor. With your venous hypertension and lack of calf muscles, your tissue isn't getting enough oxygen. You received the wrong treatment before, that's why your wound 'stalled.'"

"Stall..." Dennis let the word sit behind his lower teeth. Certainly he'd felt stalled in his life: there was that security guard job at the Ivar Apartments. People said "hi, Dennis," sometimes gave him their leftover sandwiches or a Twinkie from the basement vending machine...then what?

"Phew. That's a lot of info," Dennis said out loud, next ruminating on how Beth got him started on the "Lady Jane" cigarettes (yes, that was why he smoked girl-sounding nicotine), just before she dumped him. He sure could use a cigarette now. He lit one up. "Mind if I...?" He laughed obsequiously.

"You can't smoke in here, Dennis." Dr. Rinoie wasn't smiling. "Your physical condition is no joke. You're 74 pounds overweight. You have high blood pressure. Your diet is horrible. You've severely compromised your immune system! I want you to switch to lean proteins and to treat your condition with elevation and compression. That," Dr. Rinoie slammed his thin, strong hand down on his mahogany desk, "will heal your wound."

"Love the tough love, doc. Love the tough love," Dennis laughed again — this time with admiration. "And then you're gonna try to cut me open at some point, like you said? I mean, that's what you surgeon guys do, right? Stick sharp objects in people, then slice-n-dice?"

Dennis made a dramatic swoosh-swoosh motion in the air. It was something he saw on a late-night commercial for a potato-dicer.

"Vein surgery certainly is an option, as I mentioned," Dr. Rinoie responded. "But I'd like to try some more conservative wound management at first." Dr. Rinoie whipped out a prescription pad and a black ballpoint pen. He wrote as he spoke.

"I'd like you to wear a good compression stocking. Medi has a new 2 layer knee-high compression stocking called the 'Dual Layer'. It's a 30-40mmHg garment and is far easier to put on than traditional knee-high stockings", Dr. Rinoie continued. "Let's get that wound cleaned up...and let's get you started with a good sequential compression device to use at home. I recommend the Bio Compression 2004 with bilateral full leg appliances. That'll help move the blood that's pooling in your lower legs. Your legs will thank you."

"Okay Doc, I'll give it a go if I can remember all that."

"Don't worry. I wrote it all down. Oh." Dr. Rinoie scribbled on the pad. "I also want you to go to a good multidisciplinary wound treatment facility. The Wound Care Center at Saint Joseph is in your area. It's excellent."

With a great flourish, Dr. Rinoie tore off the pages from the prescription pad. He handed the pages to Dennis. "Now put out that cigarette, Dennis." Dr. Rinoie sternly said. "With every puff, you restrict your veins and make your blood platelets too sticky. You may not take your health seriously, but I do...and I'm sure as hell not breathing in your second-hand smoke!"

Whoa. The doc meant business. O.K., the man was small, but he was in thrumming good shape. He probably did yoga, which Dennis always thought was a weird-seeming exercise because it sounded too much like "yogurt" and because, apparently, it involved a pose called "downward-facing dog."

Still, Dr. Rinoie spoke with the kind of gravitas that dug up a musty respect from Dennis. This guy really seemed to know what he was talking about. Dennis stubbed out his "Lady Jane" on a magazine called Journal of Wound Care. "Okay, Doc. I'll do what you say."

A week later…

The Saint Joseph Wound Care Center was abuzz with people and activity.

Dennis had never had so much attentive care from so many different qualified professionals as he did at this multidisciplinary treatment facility. He had to felt good!

There was "Pete," a smiling, mustachioed podiatrist who examined and treated his feet as if they were fine art objects; another vascular surgeon, Dr. Marion Ungerleider, knowledgeable, nurturing; a plastic surgeon, Dr. Sara Stern, who always brimmed with an infectious, vibrant enthusiasm when she extrapolated about skin grafts; a couple of nurses, Tomas, from the Philippines and Annette from Hawaii, and a highly-skilled Certified Wound Care Nurse, Lupe Suarez. Wound Specialist certificates dotted the walls.

"We're going to debride your wound," Lupe said expertly, on Dennis' first visit. "That means we're going to get rid of a lot of the dead tissue. We want you on a new dressing change regiment, too...uh, we'll going to use an alginate with silver to help cleanup that wound."

Tomas swiftly brought out the dressing.

"And after we're done cleaning it up, we going to wrap your leg with a multilayer compression wrap," Annette arrived with the package with a few different rolls of bandaging. "Now, when I'm done here, you don't take this off until you return next week. Got it?"

"Okay," Dennis gravely replied. "Dr. Rinoie told us he warned you about smoking. That's important. Let's talk about other lifestyle changes. You need to shake off some of this weight. It's killing you. Cut out all the saturated fats. Up your intake of fruits, vegetables and whole grains. Don't eat fried, processed foods. If everything on your plate looks brown and fried, you're eating the wrong thing."

"And exercise," Tomas piped up. "Exercise is vital. Even if it's just walking around the block at first, just do it."

"Sure," Dennis replied. "Look, I already feel better. You guys obviously know what you're talking about. This wrap feels good. Makes me feel like there is a way to get rid of this problem."

A week later in Las Vegas…

"You want another one, honey?" Jeannine the cocktail waitress swooped in where Dennis stood at the craps table in the casino.

"Sure. That's why I'm here. I'm celebrating!" Dennis' answer came out with a loud bluster. He shoved his empty glass onto her tray. It clinked against the others.

"What'cha celebrating, hon?" Jeannine knew how to crease her smile into dimples.

"The chronic wound on my leg! It feels so much better. I'm not even gonna wear the Profore wrapping while I'm here, or use the compression pump. Why should I? I'm here to have fun. Sin City, right?"

"Right. So was that a Greyhound or a Miller Lite?"

"Hey, bring one of each. I'm celebrating! Oh, and bring lots more of those little pretzels when you come back...and some extra-salted peanuts and some barbequed potato chips, too. I like the way they all taste with the beer. And the vodka."

"You got it, hon. Congrats on the wound-healing...and good luck at the craps table."

"Hey, I've been standing here long enough. Sooner or later I'm gonna get lucky, right?" Dennis' words tumbled into a sloppy slur. "Beth, his wife, liked to gamble. You ever meet anyone named Beth? It's a pretty name. Right?"

Jeannine smiled.

Back Home a few days later…

Dennis felt bloated. And heavy. And badly circulated. And chronically wounded...again.

It was hard for Dennis to look Lupe, the nurse in the face — he felt so guilty about missing his last week's appointment.

"We missed you last week Dennis," Tomas said, sadly recognizing a common fact at the wound care center. Many patients regularly missed appointments. Compliance is a major challenge with chronic wounds.

Great. So this guy was going to lay it on, too, Dennis thought to himself.

"Yeah," Dennis muttered, looking down at the floor. "I ended up going to Vegas...kind of drank a lot, ate lots of stuff I probably shouldn't have, stood around for long hours and lost money I didn't have, oh,," Dennis said this next part quickly, hoping they wouldn't really hear it. "I, uh, didn't use the compression pump."

"Dennis!" Lupe shook a well-manicured index finger at him. Damn, these guilt-mongers were everywhere.

"You continue to treat all this as a big joke Dennis and you could end up losing this leg." Lupe gloved up, pulled out a scissors and prepared to remove his smelly bandage. "Or at the very least, a pain-riddled, infected, oozing mess of that really a good choice?"

"Nope. Um. I mean, 'No, Ma'am,'" staring at the floor."

"Okay, then," Lupe continued. "If you're not compliant with your wound care appointments and dressing changes and daily, important, effective use of both your compression garments and compression pump — then we're just going to have to discharge you."

"No, I...I don't want that. I was feeling better —"

"...And you have to work at staying better," Annette interjected.

"Scout's honor," Dennis said, cocking two fingers to his forehead, even though he'd never been a Scout.

Thirty Days Later…

"Oh, man," Dennis told Beth, on one of their many "T.V. nights."

"I can't believe I fell off the wagon before. I love getting up every morning to wrap my leg with my CircAid Juxta-Lite. They told me at the wound care center to use 40mmHg of compression, and, boy, were they right! It's just the right amount of pressure, and the thing is so cool and dry and breathable. It makes such a difference. The wound feels better every day."

Dennis had to shout a little over his elevated leg and the steady whoosh of his HCPCS, E0651 sequential compression device so that Beth could hear him.

"What's that, honey?" Beth appeared in the living room carrying a tray of low-fat, healthy foods their wound care specialists told them they should both be eating: grilled trout with rosemary, steamed broccoli, and a mixed green salad, with just a squeeze of lemon and olive oil.

"Oh, just that...elevating my leg every night and using the sequential compression pump two hours while I watch T.V.. with you, well, what could be better than that? Great company. Great wound-healing!"

Beth laughed appreciatively, picking up a sprig of rosemary with her hands. "Is 'Wheel of Fortune' on soon?"

"Yeah," Dennis said. How lucky was he to have this woman in his life? "The swelling in my leg has really gone down. It's like it was never there! And the wound? It's really shrunk in size. I can't believe it. I feel so much better!"

"I'm happy for you. Anything I can do to help?" she prodded.

"Just be yourself love," he replied.

Two Weeks Later…

It should've been a really great day.

This was the day that Dr. Marion Ungerleider, Dennis' specialist at the wound care center, told him that his wound had officially closed.

"Your venous insufficiency is better, too," Dr. Ungerleider said to Dennis, peering at him from over her square, tortoise-shell reading glasses. "We want it stay better, though, don't we?"


"And you're staying away from the fatty foods?"

"Yeah. Mostly, yeah. No. I know it's important. I've cut a lot out. I thought about what you said...'the food should look colorful and dynamic on the plate'"

"And I'm glad you're enjoying your compression pump and your CircAid Juxta-Lite. We still want you to wear the CircAid Juxta-Lite every day, using the sequential compression pump every night for at least an hour. That way, the venous stasis ulcer won't want to come back."

"And I don't want it back. It's not welcome!" Dennis said with loud cheer.

Dennis just smiled. Closure never felt so good.

The End